Had Enough of Joe Namath Yet?
WOW! There was probably a million TV commercials about Medicare during Open Enrollment this past Fall, and I think Broadway Joe was in half of them!
You probably saw more than I did, as I was working 15 hour days in October, November and December, but I heard about it at appointment after appointment. You may have wondered, “What is he talking about? You don’t get all this stuff for free!” And you weren’t about to call an 800 number to find out!
He was referring to Medicare Advantage Plans. Medicare Advantage is Part C of Medicare. It can be considered somewhat of a replacement for Original Medicare, as Medicare itself does not process your claims, the INSURANCE company you signed up with does. As such, the insurance company decides what your out of pocket costs for hospital and medical services will be. Rather than deductibles and co-insurance, like Original Medicare, many Advantage plans have fixed costs for services in the form of co-pays.
“But Joe says everything is FREE!”
I think the idea behind the ads was to get the specific attention of those whose income is low enough to qualify for a particular segment of Medicare Advantage Plans, ones geared for those on Medicaid as well as Medicare. Those with incomes below the Federal Poverty Level for their household size may be eligible for a “Dual Eligible” plan, in which case, many services are at no cost. This may include a fair amount of dental, vision and hearing coverage at little or no cost as well. I’ve been told that only half of the individuals who would qualify for such a plan, actually have one…so the insurance companies are aggressively reaching out to this segment of the Medicare population.
By calling the 800 number to see, “IF YOU QUALIFY,” it opens the door for the agent on the other end of the line to not only see if you fit the strict guidelines for a Dual Eligible plan, it allows them to offer many, many other options to you IF YOU DON’T QUALIFY.
I have nearly 900 clients on a Medicare Advantage Plan. And it’s true, most do not pay a premium for their plan. (probably 90% of my Advantage plan clients pay ZERO premium). They still have to pay for Part B of Medicare, which is $144.60 a month in 2020, but no additional cost for the plan.
Medicare Advantage is one of the main “paths” to take when you are on Medicare. The other main path being Medigap, the insurance that supplements Original Medicare. When I meet with clients, we talk about both approaches. There is no single “right path” that fits everyone. But which one is right for you? I don’t know! That’s why we get together and figure it out!
I don’t have an 800 Number. I have a local number. (717) 468-0130.
And the only thing I can promise you for FREE…is my time. You’ll never pay me anything. And I come to see you. Plus I’ve done it probably 4000 times, so I can’t guarantee a Super Bowl victory, but I feel safe guaranteeing I know what I’m talking about, and a safe bet I know more than Joe Namath!
What is the Donut Hole???
I am frequently asked 3 questions about a mysterious and misunderstood segment of Medicare Prescription Drug (Part D) coverage:
1. What is the Donut Hole?
2. How do I get in the Donut Hole??
3. How do I get out of the Donut Hole???
Whether your Medicare Prescription Drug Coverage is a “stand alone” Prescription Drug Plan or included in your Medicare Advantage Plan, it has the dreaded Donut Hole.
What is the Donut Hole? Technically it is the “Coverage Gap” in Medicare, just one segment of the 4 Part D Coverage stages:
• Deductible: If your plan has a deductible, you will pay the “Full Cost” of the drug until you meet the annual deductible, though some plans exclude some “tiers” from deductible.
• Initial Coverage: After the deductible has been met, you generally have fixed amounts to pay for your drugs—Co-pays or Co-insurance (percentage of the cost)
• Coverage Gap (Donut Hole)
• Catastrophic Coverage
How Do I Get IN the Donut Hole??
Part D Prescription Drug Coverage works on a calendar year basis, January 1st through December 31st. As you fill prescriptions throughout the year, your plan is keeping track of the “Full Cost” of your drugs. For example you may pay $3, $20 and $47 dollars for three different drugs that actually cost $11.55, $66.23 and $454.81 dollars.
If the FULL COST of your drugs added together in the calendar year reach a certain threshold, (which changes each year), it is $3750.00 in 2018…YOU ARE IN THE DONUT HOLE!!
All Plans have the Donut Hole, and what you pay for drugs changes to a percentage of the “Full Cost” your Part D Plan has for your prescriptions. In 2018 the costs are 44% on Generic drugs and 35% of Brand drugs. (the percentages change each year)
How Do I Get OUT of the Donut Hole???
Stay with me here! Your “True Out Of Pocket” (TROOP) costs must reach $5000.00 in 2018. The 5000 really has nothing to do with the 3750, it is 2 different calculations! The TROOP of 5000 is reached by adding up what YOU actually paid initially, this includes deductible if any, then co-pays/co-insurances in Initial Coverage plus the 44% on generics/35% on brands in the Donut Hole, AND the drug manufacturer of your Brand name drugs contributes 50% of the cost of the Brand drug. If this adds up 5000, then…YOU ARE OUT OF THE DONUT HOLE!!!
Now you are in Catastrophic Coverage. Costs generally go down. For 2018, you will pay the greater of 5% of the full cost of your drugs, or $3.35 for generics, $8.35 for brands. This will continue to the end of the year, and it starts all over again from the beginning on January 1st!
Pretty easy, right? LOL!
Do You Have the Right Part D Plan for 2018?
A good way to compare Rx costs on your current Part D plan for 2018 is on the official U.S. government site for Medicare:
• Go to www.medicare.gov
• Select the green tab for Find Health and Drug plans
• Enter zip code
• Step 1 Enter Information (about your current type of Medicare coverage)
• Select Current “Drug Plan” (Find your 2017 plan)
• Step 2 of 4. Enter Your Drugs. When finished click “My drug list is complete”
• Step 3 of 4. Select Your Pharmacies. You must select 1, but no more than 2
• On the next page, Step 4, Refine Your Plan Results, the choices are:
o Prescription Drug Plans (with Original Medicare)
o Medicare Health Plans with drug Coverage (aka Medicare Advantage)
o Medicare Health Plans without drug Coverage
Select “Prescription Drug Plans” and it will sort the choices in order for the projected lowest overall costs for all of 2018. “Overall” is the combined total of monthly premiums for the plan, plus the costs to fill prescriptions for all of next year. It will show prescription costs if purchased at a retail pharmacy, as well as through mail order. 2018 data should be on-line as of 10/1/17.
You will receive an Annual Notice of Change (ANOC) from your current plan provider every year at this time. This tells you about any changes for 2018.
Common Reasons for Changing Part D
• Formulary Change: The formulary is the list of drugs your plan covers. Make sure all of your drugs will be covered next year. If they are dropping any of the drugs you take, you would have to pay full price for them next year!
• Changes in the Pharmacy Network: Just because your favorite drug store accepts your plan this year, doesn’t automatically mean they will next year.
• You Now Take Brand Name Drugs: Your Rx list of will change throughout your life. Your current plan may cover your brand, but it may be cheaper on another plan.
• Drug Tier Change: Prescriptions are categorized into “tiers”. Many plans have a 5 tier system that looks like this:
1. Tier 1: Preferred Generic
2. Tier 2: Generic
3. Tier 3: Preferred Brand
4. Tier 4: Non-Preferred Drug
5. Tier 5: “Specialty” Drugs
If some of your drugs have switched tiers, you may pay more for them next year.
• Big Increase in Plan Premium: How much is too much? It’s up to you, but it makes sense to check and see if another plan is significantly more cost effective.
How Many Phone Calls About Medicare do YOU Get???
If you still have a “land line” phone in your home, chances are very good that agents or telemarketers from insurance companies will call you repeatedly to pitch their Medicare Insurance product(s) to you. They call from all over the country: Texas, Oregon, Florida, etc.
They don’t leave messages. Do you know why they don’t? They know you won’t call them back!
Over 95% of the time when I meet with people to explain options with Medicare Insurance, it is in their home. I have no problem driving up to an hour from my house in Ephrata to where my clients live, typically somewhere in Lancaster, Berks or Lebanon County. It is not uncommon for such phone solicitations to happen 2 or 3 times in the hour that I am in their house!
Some people, in a moment of weakness, or purely by accident, actually answer one of these calls. Shockingly, some people, some really otherwise intelligent people, buy whatever the person on the other end of the line is selling! Now, some of these agents who solicit over the phone, may actually know what they’re talking about. Some may actually be brokers, and can offer multiple companies as options.
Some.
I feel the decisions to be made about your health insurance for the REST OF YOUR LIFE is a little too important to be made over the phone, with anyone, let alone someone on the other end of an 800 Number.
The phone IS necessary…to set up a time to get together face to face, one on one. I DO NOT SOLICIT BY PHONE, I only use the mailbox. I will certainly call you back, but you’ve got to start the ball rolling by calling me first at (717) 468-0130.
I hope to hear from you soon!
You Look Comfortable!
With a warm smile, that’s what a new client said to me today, “You look comfortable!”
Yes it was another sunny September day in scenic Lancaster County, 10 am, first appointment of the week and I was well rested and ready to go. However I think it had more to do with the contentment and joy in doing what I do. Perhaps some of it is being completely confident in what I do. I meet over 500 NEW people each year. I’ve met with THOUSANDS of people about Medicare insurance. The basics are the same, the presentation is the same, but the people are all different. Each person is an individual, so each time it feels brand new, and it’s fun!
Yes. I AM COMFORTABLE!